2.0 Analysis 2.1 Decisions Relevant to the Incident During the course of the incident, four key decisions were made which impacted on the development and extent of the fire and had significant ramifications with respect to the safety of the vessel. It was decided to stop the conveyors pending resumption of unloading; to enter the tunnel area through the W/T door in the engine-room; to flood the tunnel to fight the fire; and to resume ventilation of the tunnel area when the fire first appeared to have been brought under control. 2.2 Stopping the Conveyor System It was decided to stop the conveyor system pending the resumption of the unloading operation to prevent the movement of the belts from aggravating the dust problem and thus delaying the clearing of the atmosphere in the tunnel. It was not likely that a heat source, sufficient to ignite the stationary belt, had developed in the hardware of the conveyor system. As the heat source was not detected before the belt conveyor system was stopped, there was no reason to take such a possibility into account when the decision to stop the belt was taken. 2.3 Watertight Door to Tunnel When heat transference and intensification indicated that the application of water through the loop belt casing was not being successful, it was decided to attempt to tackle the fire directly by entering the tunnel area through the W/T door in the engine-room. After the fire party was forced to withdraw, the W/T door could not be closed from either of the two remote-control positions due to the heat. It was provident that a spring-loaded fire door had been fitted on the engine-room side of the W/T door. The fire door closed automatically and is considered to have played a large part in saving the ship. It was not determined if the existence of the fire door was critical in making the decision to use the W/T door. 2.4 Tunnel Flooding and Stability The introduction of water into the tunnel in order to submerge the conveyor system created a free-surface area which, under the sheltered conditions of the harbour where there was no motion of the ship, presented little danger of significant stability loss. Under different circumstances, where motion could have been imparted by external forces, such as wind and seas or by a cargo shift, and particularly if at sea when subject to rolling and pitching, the dynamic surging of the water would not only cause massive adverse effects on stability but could also cause considerable structural damage. In this instance, partial cargo discharge and compensatory ballasting maintained the ship's initial transverse stability; however, the vessel's stability information gave no guidance for shipboard personnel on the effect of flooding the tunnel. 2.5 Opening Up the Fire Site When the fire first appeared to have been brought under control, those involved in the fire-fighting efforts had to decide on a continuing course of action. The ship's officers, all of whom had received training in fighting shipboard fires, wanted to keep the fire site closed with continued application of water. However, they were unaware that the shore-based fire-fighters had no training in fighting shipboard fires, and they allowed themselves to be persuaded by shore personnel to open up and so ventilate the fire site. It cannot be stated with certainty that the ensuing, more intense, conflagration would not have occurred under the more passive approach favoured by the vessel's personnel. However, the events, and the further endangering of the vessel, would suggest that it might have been prudent for the ship's officers to have stood by their convictions. 2.6 Cold Weather Operations Preparations made by the crew of the AMBASSADOR had included readying the vessel's fire main for operation in cold weather conditions. In the existing extreme conditions, the preparations proved ineffective. Only one outside deck hydrant was usable to fight the fire, as all the others were frozen. The extreme cold weather conditions hampered the fire-fighting efforts. 3.0 Conclusions 3.1 Findings During unloading, considerable difficulty was experienced in preventing cargo from spilling from the conveyors. The dust from spilled cargo in the tunnel was so thick that crew members found it necessary to suspend the unloading and leave the area. The empty conveyor belt system was stopped, pending the resumption of the unloading operation. A section of the stationary conveyor system came into contact with a heat source that caused the belting to ignite. The fixed sprinkler system in the loop belt casing was ineffective in controlling a major fire. The open top of the loop belt casing and the hopper gates to No.3 hold, which were not airtight, allowed a continuous supply of oxygen to the fire. The preparations of the vessel's fire main for operation in cold weather proved ineffective in the existing extreme conditions and all deck hydrants but one were frozen. Additional hoses had to be led from engine-room hydrants through the accommodation to the loop belt casing. After being opened in an unsuccessful attempt to fight the fire, the watertight (W/T) door between the engine-room and the tunnel could not be closed. A spring-loaded fireproof door on the engine-room side of the W/T door closed automatically and prevented the fire from directly entering the engine-room. Intentional flooding of the tunnel was instituted to extinguish fires in that area. Compensatory ballasting, supplementing the partial discharge of cargo, ensured that the vessel maintained positive initial transverse stability when the tunnel was flooded. The vessel's stability information gave no guidance on the effect of flooding the tunnel on the vessel's stability. The routine maintenance and testing regime of safety equipment proved ineffective. The crew had not been drilled in fire-fighting during weekly emergency musters and was consequently unaware of the condition of the equipment. Although the vessel had passed a safety equipment inspection by a classification society surveyor only two months earlier, some of the shipboard fire-fighting equipment was sub-standard. The Port Authority had not provided the ship with instructions on emergency alert procedures. The Port Authority did not require a fire plan to be available and accessible to shore-based fire-fighters. None of the shore-based fire-fighters had been trained in fighting shipboard fires. There were no shore fire cabinets close to the scene of the fire. The Canadian Coast Guard (CCG) had earlier declined to approve or endorse the owners' plan to upgrade the fire-fighting installation in the self-unloading system due to the absence of guidelines or regulatory requirements. Housekeeping standards in the work area were such that the debris in the tunnel compromised safety. Open fire doors in the accommodation facilitated the spread of fire between cabins. The extreme cold weather conditions hampered the fire-fighting efforts. 3.2 Causes When the conveyors were stopped, a section of one of the conveyor belts ignited, probably because the belt was in contact with an overheated roller. The roller probably overheated due to a bearing failure or to being jammed with refuse which ignited after contacting the overheated bearing. 4.0 Safety Action 4.1 Action Taken 4.1.1 Ship Management Practices Following the occurrence, the owners/operators took the following measures: produced a fire safety training video and circulated copies on fleet vessels during safety briefings; conducted an in-depth fire safety audit of fleet vessels with special attention to maintenance of fire doors and the importance of keeping fire doors closed; improved training on fire drills and provided masters and crews with additional instructions regarding fire prevention and safety procedures; and extended the duration of the safety (inspection) round after each shut-down of the conveyor(s). 4.1.2 Emergency Procedures As a result of this occurrence, the Port of Belledune reviewed its emergency procedures and developed a new Port Emergency Plan to deal with emergencies such as a shipboard fire. Some aspects of this plan were tested in the spring 1996. Also, the Port Authority installed signs on the wharf indicating the telephone number to use in case of emergency. 4.2 Action Required 4.2.1 Shore-based Fire-fighting Capabilities In the last 10 years, there have been 386 occurrences involving fires or explosions on board ships in Canadian ports; approximately 32percent of these occurred in the winter months. Some 20percent of all the occurrences happened in ports under Ports Canada's jurisdiction; the remainder occurred in smaller locations under Transport Canada's Harbours and Ports or in Department of Fisheries and Oceans (DFO) harbours. Shortcomings in the fire-fighting capabilities of some ports and harbours were evident in these occurrences. For example, an inadequate water supply and a lengthy distance to the fire hydrant hampered the fire-fighting efforts in freezing temperatures on an out-of-control fire in the loop conveyor belt system of the ALGOSOO undergoing repairs at Port Colborne, Ontario, in 1986 (Report CCGMCI-442). Three years later, in September 1989, again at Port Colborne, it took the local fire department some 12 hours to fight another conveyor belt fire on board the H.M.GRIFFITH (CCGMCI-540). In July 1991 in Vancouver Harbour, British Columbia, a fire destroyed the Kitsilano Canadian Coast Guard Base and four vessels (TSB Report No.M91W0003). The fire response craft at the scene were not equipped to fight a fire of a large magnitude. Nor did the city water line have adequate pressure; it subsequently broke while being used to fight the fire. In the recent occurrence at Belledune, New Brunswick, inadequate knowledge of shipboard fire-fighting techniques, by both the ship's crew and shore-based fire brigades, led to confusion. While most vessels are equipped with an on-board, self-contained fire-fighting system, capable of mitigating the danger posed by fires at sea, these same vessels can have their fire-fighting capability severely limited in port, as much of their main and auxiliary equipment is not running and/or readily available. It is not just the vessels that are vulnerable to extensive damage by shipboard fires when in port; vessel fires at dockside also present a serious hazard to port facilities and installations (as evidenced in the occurrence at Kitsilano). Within ports and harbours, the responsibility for providing an emergency response plan, including fire-fighting assistance for vessels in port, generally rests with the port management. These plans often rely on municipal fire departments for fire-fighting support, many of which do not have personnel properly trained to fight shipboard fires. The Board believes that, with the ever-present risk of on-board fires, a well trained and equipped fire response team is essential in order to minimize the consequences of an out-of-control fire in the close confines of a port or harbour. Therefore, given that some Canadian ports and harbours appear to lack the proper facilities and resources to effectively contain shipboard fires occurring within their jurisdiction, the Board recommends that: The Department of Transport conduct a special audit of fire-fighting facilities at Canadian ports and harbours under its jurisdiction to ensure that an adequate year-round capability exists to contain shipboard fires; The Department of Transport, in collaboration with ports and harbour authorities, take measures to ensure that shore-based fire brigades expected to support on-board fire-fighting, receive appropriate training. In this occurrence, the crew of the AMBASSADOR, as a result of inadequate fire drills and equipment inspections during cold weather operations, was not aware of the degraded condition of the ship's fire-fighting equipment and frozen deck hydrants. Canadian ports and harbours annually receive hundreds of foreign-registered vessels, many originating from warmer climates and crewed with personnel who are not familiar with the harsh winter conditions found in Canada. The Board understands that, following this occurrence, the owners of the AMBASSADOR took measures to ensure a better fire-fighting capability in their fleet for cold weather operations. However, based on observations of other occurrences, the Board believes that many of the vessels and crews arriving in Canadian waters during the winter months will continue to be poorly prepared to cope with extraordinary situations, such as a fire-fighting response, in extreme cold. Therefore, the Board recommends that: The Department of Transport take appropriate measures to ensure that on-board fire-fighting capabilities of vessels in Canadian ports and harbours are functional and readily available during cold weather operations. 4.2.2 Fire Safety on Self-unloaders The TSB is aware of at least nine fires involving conveyor belt systems on self-unloading ships in Canadian waters in the last 15 years. None of the vessels involved was fitted with a fire-detection or fixed remote fire-fighting system capable of suppressing large fires, and all nine fires required direct fire-fighting by ship personnel. Fires during self-unloading operations are generally the result of flammable and/or combustible cargo dust in the confined tunnel areas coming in contact with a heat source such as friction in the conveyor belt systems. On the AMBASSADOR, the fixed sprinkler system in the loop belt casing proved ineffective in controlling the spread of the fire in the tunnel, and the area of the fire was not covered by a remote fire-fighting system. When the AMBASSADOR was previously registered in Canada, the ship's owners approached the Canadian Coast Guard (CCG) with a plan to enhance the vessel's fire-fighting capability in the self-unloading system. However, there are no regulatory requirements for remote fire-fighting systems, and the CCG declined to approve or endorse the owners' plan to upgrade the fire-fighting installation. In view of the inherent risk of tunnel fires in self-unloaders and the demonstrated inadequacy of existing on-board fire protection systems, the Board recommends that: The Department of Transport review the requirements for fire protection systems for tunnel areas on Canadian self-unloaders, with a view to ensuring a capability for suppressing large fires. On the Great Lakes, self-unloading vessels are the primary means of transporting dry bulk cargoes. At present, some 80 self-unloaders operate primarily on the Great Lakes and connecting waterways; over 30 of these vessels are Canadian, the remainder are registered in the United States. Any of the vessels engaged in bulk cargo trade may transit through Canadian waters and may call at Canadian ports. These Great Lakes vessels are regulated by Canadian and U.S requirements only. The Board believes that the Canadian marine environment and supporting infrastructure should not be exposed to greater risks from U.S. vessels than from Canadian vessels. Further, any competitive disadvantage for Canadian vessels resulting from more stringent Canadian requirements may lead to cutting safety margins. Therefore, the Board recommends that: The Department of Transport, in conjunction with the appropriate authorities in the United States, seek harmonization in the requirements for fire detection and extinguishing systems on Great Lakes self-unloading vessels. In addition, several foreign self-unloading vessels such as the AMBASSADOR call at Canadian ports every year. Present international regulations on Fire Protection, Fire Detection and Extinction of SOLAS (IMO Safety of Life at Sea) do not address requirements specific to tunnel fires on self-unloading vessels. Therefore, the Board recommends that: The Department of Transport seek support from the International Maritime Organization in addressing the need for enhanced fire detection and extinguishing systems in the tunnel area of self-unloaders. The Board recognizes in making these recommendations that the consultation processes for establishing the requirements for enhanced fire-fighting systems can take considerable time. Therefore, the Board believes that interim measures need to be taken to ensure that existing fire-fighting capabilities in the tunnel areas of self-unloaders are not jeopardized. In this occurrence, the existing fire station in the tunnel of the AMBASSADOR had been rendered ineffective at the time of the fire. The small flexible rubber hoses that had been left connected to fire hydrants for washing down the area were not suitable for fire-fighting. Similarly, in a previous occurrence involving the Canadian self-unloader HALIFAX, flexible one-inch wash-down hoses were also found connected to hydrants of tunnel fire stations (TSB Report No.M93C0001). Any time lost in combatting a tunnel fire can quickly exacerbate the severity of the situation. Since the current practice of ships' operators and crews of leaving non-fire-fighting hoses and equipment attached to fire stations render them, at least temporarily, unavailable for their primary purpose, the Board recommends that: The Department of Transport take immediate measures to ensure that the readiness of fire stations in tunnels of self-unloading vessels is not jeopardized by the industry practice of using such stations for purposes other than fire-fighting.